fire fighter face report no. 98-06, single-family …and one driver/operator were the first...

The Fire Fighter Fatality Investigation and PreventionProgram is conducted by the National Institute forOccupational Safety and Health (NIOSH). The purpose ofthe program is to determine factors that cause orcontribute to fire fighter deaths suffered in the line ofduty. Identification of causal and contributing factorsenable researchers and safety specialists to developstrategies for preventing future similar incidents. Torequest additional copies of this report (specify the casenumber shown in the shield above), other fatalityinvestigation reports, or further information, visit theProgram Website at:

http://www.cdc.gov/niosh/firehome.html

or call toll free 1-800-35-NIOSHFigure: Basement where fatalities occurred.

Single-Family Dwelling Fire Claims the Lives of Two Volunteer FireFighters--Ohio

SUMMARYOn February 5, 1998, two male volunteerfire fighters (Victim #1 and Victim #2) diedof smoke inhalation while trying to exit thebasement of a single-family dwelling aftera backdraft occurred. A volunteer Enginecompany composed of four fire fightersand one driver/operator were the firstresponders to a structure fire at a single-family dwelling 3 miles from the firedepartment. When the Engine companyarrived, one fire fighter on board reportedlight smoke showing from the roof. Thefour fire fighters (including Victim #1)entered the dwelling through the kitchendoor and proceeded down the basementstairs to determine the fire’s origin. Thefour fire fighters searched the basementwhich was filled with a light to moderatesmoke. A few minutes later, a fifth firefighter from Rescue 211 (Victim #2) joinedthe group. After extinguishing a small firein the ceiling area, Victim #2 raised aceiling panel and a backdraft occurred inthe concealed ceiling space. The pressure

and fire from the backdraft knocked ceilingtiles onto the fire fighters, who becamedisoriented and lost contact with eachother and their hoseline. Two fire fighterslocated on the basement staircase exitedthe dwelling with assistance from two firefighters who were attempting rescue. Onefire fighter was rescued through an exteriorbasement door and the two victims’ SCBAsran out of air while they were trying toescape. Both fire fighters died of smokeinhalation and other injuries. Additionalrescue attempts were made by other firefighters but failed due to excessive heatand smoke and lack of an establishedwater supply. NIOSH investigatorsconcluded that, in order to prevent similarincidents, fire departments should:

! utilize the first arriving enginecompany as the commandcompany and conduct an initialscene survey

Single-Family Dwelling Fire Claims the Lives of Two Volunteer Fire Fighters--Ohio

! implement an incident commandsystem with written standardoperating procedures for all firefighters

! provide a backup hose crew

! provide adequate on-scenecommunications includingfireground tactical channels

! train fire fighters in the variousessentials of, but not limited to,how to operate in smoke-filledenvironments, basement fireoperations, dangers of ceilingcollapse, ventilation practices,utilizing a second hoselineduring fire attack, and identifyingpre-backdraft, rollover, andflashover conditions

! appoint an Incident SafetyOfficer.

INTRODUCTIONOn February 5, 1998, five male volunteer firefighters, including the two victims, ages 43 and29 years old, entered a single-family dwelling thathad light smoke showing from the roof. The firefighters entered the dwelling through the kitchendoor and proceeded down the basement stairs todetermine the fire’s origin. After extinguishing asmall ceiling fire, a ceiling tile was lifted and abackdraft occurred in the concealed ceiling spacewhich disoriented the fire fighters. Two firefighters died of smoke inhalation and otherinjuries, one fire fighter had to be rescued, and theother two fire fighters escaped with someassistance.

On February 10, 1998, Richard Braddee andTommy Baldwin, Safety and Occupational HealthSpecialists from the Division of Safety Research,traveled to Ohio to conduct an investigation ofthis incident. Meetings were conducted with firedepartment officers, the surviving three volunteerfire fighters of the initial fire attack crew, and arepresentative from the local Fire InvestigationTask Force. Copies of photographs of theincident site and the transcription of dispatchtapes were obtained, and a site visit wasconducted. The 33-member volunteer firedepartment involved in the incident serves apopulation of 7,800 in a geographic area of 84square miles. The fire department requires allnew fire fighters to complete Fire Fighter Level Itraining which consists of 36 hours of training andis required by the State of Ohio. The requiredtraining is designed to cover personal safety,forcible entry, ventilation, fire apparatus, ladders,self-contained breathing apparatus, search andrescue, and hose practices. Recertification in-service training is conducted on an annual basis.The victims had approximately 5 and 10 years offire fighting experience, respectively. The firedepartment had an active equipment inspectionand maintenance program. Any equipment foundto be defective was repaired or replacedimmediately.

The site of the incident was a 20-year-old, one-story, single-family residence measuring 28' x 50'.The ranch-style residence was constructed ofwood framing, had a shingled roof and hardboardsiding. The residence had a 26-foot-long deckattached to the west side and a full basementabout 8 ½-feet high with a 16-inch droppedceiling. Access to the basement was gainedthrough either an interior stairway from thekitchen or an exterior stairway which was locatedon the north side of the residence. The residence


contained a full kitchen both upstairs and in thebasement, had full carpeting, and was heated by anatural gas furnace. Three smoke detectors werepresent in the residence, but the occupant statedthey did not operate. The residence was about 3miles from the fire department involved in theincident.

Although eight volunteer fire departments wereinvolved in this incident, only those directlyinvolved up to the time of the fatal incident arementioned in this report.

INVESTIGATIONOn February 5, 1998, at 0210 hours, a fire callwas received by the Sheriff’s Office from theoccupant of a private residence near the incidentsite. The Sheriff’s Office dispatched theautomatic response group for structure fireswhich consisted of three local volunteer firedepartments. At 0220, Engine 211 with four firefighters and a driver/operator, including Victim#1, responded to the alarm. Rescue 211 with theChief and two fire fighters, including Victim #2also responded. Additionally Squad 211(ambulance), and Tanker 211 responded with sixpersonnel. Altogether 4 pieces of equipment and13 personnel arrived at the fire scene between0226 and 0231 hours. By 0238 hours, all threeautomatic response fire department units were onthe scene.

Engine 211 crew were first to arrive at 0226hours and reported that smoke was showing fromthe roof. A 1¾-inch crosslay handline was pulledand laid to the kitchen door. Information wasrelayed by a relative of the owner of the dwellingto the Engine 211 crew that heavier smoke hadbeen observed in the southwest corner of thebasement, possibly at the circuit breaker boxunder the stairway. The Engine 211 crew

prepared to enter the house by arming their PASSdevices, turning on their SCBAs, and checkingeach others’ gear. The 1¾-inch handline wascharged, and upon entry into the kitchen, theynoticed light smoke. Rescue 211 arrived at 0227hours with the Chief and two fire fighters,including Victim #2, and the Chief assumedcommand. The Engine 211 driver/operatorrequested a supply line be laid to the tanker andthe Chief assisted in laying the line. The Chiefreturned to the residence and saw light graysmoke emanating from the kitchen door. Whileinside the residence, four of the fire fighters fromEngine 211 encountered a closed, interior doorleading to the basement. The fire fighters openedthe basement door and proceeded down thebasement steps. Victim #1 and another firefighter, who carried a two-way VHF radio, stayedat the top of the steps and helped advance hose.Three fire fighters, two of whom were carryingthe charged hoseline, began a right-hand searchpattern to locate the circuit breaker box. Afterfinding no fire at the breaker box, the crew movedto another part of the basement. As the crewprogressed back around the steps, their hoselinebecame caught between the legs of a metalfolding chair. As they advanced the hoselinefurther into the basement, the chair was pulledunder the staircase and collapsed onto the hosewhich pinched off the water supply. In theinterim, Victim #2, who also carried a two-wayVHF radio, broke the window from the exteriorbasement door then opened the door and yelled tothe interior crew that this was a second way out.Victim #2 went back up the exterior stairwell thenentered the kitchen on the first floor and metanother fire fighter who yelled down the stairsthat he and Victim #2 would search the first floor.A second 1¾-inch hoseline was pulled off Engine211, taken into the first floor kitchen through theinterior door and laid partially down the steps into


the basement. The line was charged inanticipation of being used in the basement fireattack. The fire fighters in the basement saw lightto moderate gray, puffing smoke at the basementceiling and then lazy orange flames from theceiling area. The two fire fighters includingVictim #2, went down the interior stairs andfollowed the hoseline and joined the three firefighters in the basement. They were advised toget down because the fire was in the ceiling area.They saw a small fire at a fluorescent light fixturemidway in the basement between the interiorstaircase and the northeast corner (see Figure).This fire was extinguished with the last availablewater due to the hose being pinched off. Thecrew, unaware of the water situation, waited amoment to watch conditions. Fire then traveledacross the ceiling and re-entered the walls andseveral fire fighters saw the smoke puffing outfrom between the ceiling and wall. Victim #2then passed by the crew and used an axe to lift aceiling tile in the center of the basement to checkflame spread. The concealed ceiling space hadreached the smoldering stage (i.e., hightemperatures and considerable quantities of sootand combustible fire gases had accumulated) andwhen the ceiling tile was lifted, oxygen wasintroduced into the ceiling space and a backdraftoccurred. Seconds after the backdraft, visibilitywent black and ceiling tiles collapsed onto the firefighters from the pressure created by thebackdraft. Disoriented from the heat and smokeand fallen ceiling tiles, the fire fighters begancrawling out of the basement following thehoseline, but soon lost the hose. Victim #2 tolda fire fighter to hit the fire with water from thehoseline, which he attempted, but there was nowater in the hose. At 0243 hours a radiotransmission was given “In the basement...sendwater” (charge the hoseline with water). Fire hadvented up the stairway and burned through both

hoselines, causing them to burst and freely flowwater. The crew began to crawl back toward thestaircase with Victim #1 in front, and the otherfire fighters following. The PASS devices ofVictims #1 and #2 began to sound due to heatactivation and the SCBA low-air alarms alsobegan to sound. At 0243 hours, Victim #2radioed for help and the Chief ordered theapparatus air horns sounded for all to evacuatethe house. The crew in the basement heard thehorns. At 0244 hours, another radio transmission“Need water!” was received from the basement.One fire fighter, suffering from the intense heat,became unconscious and collapsed to the floor.Another fire fighter remembered the direction ofthe second exit and continued to feel for the hoseas he tried to orient himself. He then foundanother fire fighter and they went up the steps andwere assisted out of the house by the rescue team.At 0245 hours, the radio transmission “Guysinside to IC” (Incident Command) was received.The Chief began to advance a 2½-inch hoselinedown the exterior basement stairwell to assistwith fire extinguishment and heard PASS devicessounding from inside the basement. He wasdriven back by heat and smoke. He advised hisAssistant Chief of the situation, relinquishedcommand to the Assistant Chief, and went toSquad 211 to recover.

One of the fire fighters who had just exited theresidence informed the rescuers that other firefighters were still inside. A two-person rescuecrew entered the basement from the exterior doorand rescued the unconscious fire fighter who wasabout 3 feet from the door. At 0303 hours, aradio transmission was received from Squad 211:“We have two fire fighters that are in criticalcondition.” Four additional attempts were madeto rescue the victims but the rescuers were drivenback due to intense heat and fire. The bodies


were later recovered after the fire wasextinguished. A post-incident investigationrevealed the point of origin of the fire was in thearea of the furnace.

CAUSE OF DEATHThe cause of death listed by the medical examinerwas asphyxiation due to smoke inhalation, burnsand crushing trauma injuries to the chest.

RECOMMENDATIONS/DISCUSSIONRecommendation #1: Fire departments shouldutilize the first arriving engine company as thecommand company and conduct an initialscene survey.2, 3, 4

Discussion: Since incident command and size-upare the responsibility of the first officer on-scene,the first arriving engine company shouldconcentrate its efforts on establishing a commandpost, performing initial size-up, coordinatingcommunications, and relaying information andadditional requirements to dispatch. Scene safetyis greatly enhanced by waiting to performoperations until adequate resources are on-scene.An initial scene survey, or size-up, should occurat each incident. Size-up is an evaluation madeby the officer in charge which enables him todetermine his course of action and to accomplishhis mission. A fire situation can changedrastically and rapidly. The commanding officermust quickly survey and analyze the situation andquickly weigh the various factors. Factors toconsider include: the type of occupancy, nature ofthe fire situation, structure involved, and the fireitself. Based on evaluation of these factors, thecommanding officer should decide what actionshould be taken to control the emergency. Thenext step is to formulate a plan of operation giventhe resources available, and implement that plan.

Recommendation #2: Fire departments shouldimplement an incident command system with written standard operating procedures for allfire fighters.1, 2, 4

Discussion: The system should establish rolesand responsibilities for all personnel involved. Itshould ensure personnel accountability and safetyand should provide a well-coordinated approachto all emergency activities. All fire departmentpersonnel should be thoroughly trained on thissystem and receive periodic refresher training. Alltraining should be documented.

Recommendation #3: Fire departments shouldprovide a back-up hose crew.1, 2, 3, 5, 6

Discussion: A second manned attack hoselineshould be established to provide back-up for theinitial attack line to assist with fire extinguishmentand fire fighter rescue. The National FireProtection Association (NFPA) and theOccupational Safety and Health Administrationrecommend that four persons (two-in and two-out), each with protective clothing and respiratoryprotection be provided when interior operationsare taking place. Also, a rapid intervention teamshould be established to effect fire fighter rescue.NFPA 1500, 6-5.2 states that “A rapidintervention crew shall consist of at least twomembers and shall be available for rescue of amember or a team if the need arises. Rapidintervention crews shall be fully equipped with theappropriate protective clothing, protectiveequipment, SCBA, and any specialized rescueequipment that might be needed given thespecifics of the operation under way.”

Recommendation #4: Fire departments shouldprovide adequate on-scene communications


including fireground tactical channels.1, 2, 4, 6

Discussion: Communication should be an on-going component of on-scene operations. NFPA1561 states that the communications system shallmeet the requirements of the fire department forroutine and large-scale emergencies. Emergencyscenes become very hectic within a short periodof time. Radio communications occurringbetween incident command, attack crews, pumperoperators, mutual aid companies, and dispatchcan easily be missed. It is imperative that on-scene operations be given fireground tacticalradio channels which are separate from thenormal dispatch frequencies. Fire fightersoperating on-scene must be capable ofcommunicating between themselves and incidentcommand without being “talked over” by dispatchor other companies. In a small fire department,one radio channel for dispatch and one fireground communications channel might besufficient for most situations. A larger firedepartment requires several additional radiochannels to provide for the volume ofcommunications relating to routine incidents andfor the complexity of multiple alarm situations.Interior attack crews should have adequate radiocommunication with incident command and withother attack crews to provide for personnelaccountability, coordination of efforts, report onflame spread, fire extinguishment, and otherpertinent information. As incident commandbecomes aware of changing conditions, vitalinformation can be given directly to the attackcrews. The radio capabilities should also providefor communications with mutual aid resources orother agencies that could be expected to respondto a major incident. The system should bedeveloped to provide reserve capacity forunusually complex situations where effectivecommunications could become critical.

Recommendation #5: Fire departmentsshould train fire fighters in the variousessentials of how to operate in smoke-filledenvironments, basement fire operations,dangers of ceiling collapse, ventilationpractices, utilizing a second hoseline during fireattack, and identifying pre-backdraft, rollover,and flashover conditions.2, 3, 6, 7

Discussion: The essentials of fire fighting arenumerous and varied, and require initial andrefresher training on a monthly, annually, or an asneeded basis. NFPA 1500 recommends that allpersonnel who may engage in structural firefighting participate in training at least monthly.Ideally, this monthly training will serve toreinforce safe practices until they becomeautomatic. Other types of training are requiredon an “as needed” basis. For example, training isrequired when new procedures or equipment areintroduced.

Recommendation #6: Fire departments shouldappoint an Incident Safety Officer.3, 4, 8

Discussion: The Incident Safety Officer (ISO) isappointed by the Incident Commander at each emergency scene. The duties of the ISO are tomonitor the scene and report the status ofconditions, hazards, and risks to the incidentcommander, ensure fire fighter rehabilitationoccurs, the personnel accountability system isbeing utilized, and monitor radio communicationsto ensure all areas of the scene are capable ofcommunicating to incident command.

References:1. 29 Code of Federal Regulations

1910.120(q)(3), Hazardous WasteOperations and Emergency Response.(Incident Command, Two-In/Two-Out


Rule, Communications).

2. Essentials of Fire Fighting, 3rd edition,Fire Protection Publications, 1998.(Incident Command, Back-Up HoseCrew, Rapid Intervention Team,Communications).

3. National Fire Protection Association.N FP A 1 5 0 0 , * S t a n d a r d o nFireDepartment Occupational Safety andHealth Program. National Fire ProtectionAssociation, Quincy, MA. (Back-UpHose Crew, Rapid Intervention Team)1997 Edition.

4. National Fire Protection Association.NFPA 1561, Standard on FireDepartment Incident ManagementSystem. National Fire ProtectionAssociation, Quincy, MA. (IncidentCommand, Communications), 1995Edition.

5. Dunn Vincent. Hoseline Placement atStructural Fires, Firehouse, August 1997

.6. Dunn Vincent. Safety and Survival on the

Fireground, PennWell, Tulsa, Oklahoma,1992.

7. Dunn Vincent. Collapse of BurningBuildings, PennWell, Tulsa, Oklahoma,1988.

8. National Fire Protection Association.NFPA 1521, Standard for FireDepartment Safety Officer. National FireProtection Association, Quincy, MA,

1997 Edition.


Figure: Basement where fatalities occurred.


Figure. Fire DwellingBasement Floor Plan

FACE 98F06One-story, 20-year old single-family dwelling with full basement measuring 28' x 50'. Wood-frame construction with shingle roof and hardboard siding. Three smoke detectorspresent-none operable.

fire fighter face report no. 98-06, single-family …and one driver/operator were the first...

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